Screening for primary aldosteronism in patients newly diagnosed with hypertension would maximise treatment benefits and minimise end-organ damage
Hypertension is the second leading risk factor for death and disability globally.1 In Australia, 6 million adults are affected2 and, on the basis of the evidence we discuss in this article, a significant proportion may have primary aldosteronism (PA) as a secondary cause of their hypertension. PA, of which a subset has been known as Conn syndrome, is a disease characterised by excessive autonomous aldosterone production.3 Contrary to the traditional teaching that this is both rare and benign, PA is common, specifically treatable, and associated with significant cardiovascular morbidity and mortality.4-6
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- 1. Campbell NR, Khalsa T, Lackland DT, et al; World Hypertension League Executive. High blood pressure 2016: why prevention and control are urgent and important. The World Hypertension League, International Society of Hypertension, World Stroke Organization, International Diabetes Foundation, International Council of Cardiovascular Prevention and Rehabilitation, International Society of Nephrology. J Clin Hypertens (Greenwich) 2016; 18: 714-717.
- 2. National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults, 2016. Melbourne: National Heart Foundation of Australia; 2016. https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf (viewed May 2018).
- 3. Conn JW. Presidential address. I. Painting background. II. Primary aldosteronism, a new clinical syndrome. J Lab Clin Med 1955; 45: 3-17.
- 4. Stowasser M, Gordon RD. Primary aldosteronism: changing definitions and new concepts of physiology and pathophysiology both inside and outside the kidney. Physiol Rev 2016; 96: 1327-1384.
- 5. Catena C, Colussi G, Nadalini E, et al. Cardiovascular outcomes in patients with primary aldosteronism after treatment. Arch Intern Med 2008; 168: 80-85.
- 6. Milliez P, Girerd X, Plouin PF, et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol 2005; 45: 1243-1248.
- 7. Hannemann A, Wallaschofski H. Prevalence of primary aldosteronism in patient’s cohorts and in population-based studies — a review of the current literature. Horm Metab Res 2012; 44: 157-162.
- 8. Piaditis G, Markou A, Papanastasiou L, et al. Progress in aldosteronism: a review of the prevalence of primary aldosteronism in pre-hypertension and hypertension. Eur J Endocrinol 2015; 172: R191-R203.
- 9. Käyser SC, Dekkers T, Groenewoud HJ, et al. Study heterogeneity and estimation of prevalence of primary aldosteronism: a systematic review and meta-regression analysis. J Clin Endocrinol Metab 2016; 101: 2826-2835.
- 10. Gordon RD, Ziesak MD, Tunny TJ, et al. Evidence that primary aldosteronism may not be uncommon: 12% incidence among antihypertensive drug trial volunteers. Clin Exp Pharmacol Physiol 1993; 20: 296-298.
- 11. Monticone S, Burrello J, Tizzani D, et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. J Am Coll Cardiol 2017; 69: 1811-1820.
- 12. Young MJ, Rickard AJ. Mineralocorticoid receptors in the heart: lessons from cell-selective transgenic animals. J Endocrinol 2015; 224: R1-R13.
- 13. Savard S, Amar L, Plouin PF, Steichen O. Cardiovascular complications associated with primary aldosteronism: a controlled cross-sectional study. Hypertension 2013; 62: 331-336.
- 14. Catena C, Colussi G, Sechi LA. Treatment of primary aldosteronism and organ protection. Int J Endocrinol 2015: 597247.
- 15. Lumachi F, Ermani M, Basso SM, et al. Long-term results of adrenalectomy in patients with aldosterone-producing adenomas: multivariate analysis of factors affecting unresolved hypertension and review of the literature. Am Surg 2005; 71: 864-869.
- 16. Wachtel H, Cerullo I, Bartlett EK, et al. Long-term blood pressure control in patients undergoing adrenalectomy for primary hyperaldosteronism. Surgery 2014; 156: 1394-1403.
- 17. Williams TA, Lenders JWM, Mulatero P, et al. Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. Lancet Diabetes Endocrinol 2017; 5: 689-699.
- 18. Muth A, Ragnarsson O, Johannsson G, Wängberg B. Systematic review of surgery and outcomes in patients with primary aldosteronism. Br J Surg 2015; 102: 307-317.
- 19. Rehan M, Raizman JE, Cavalier E, et al. Laboratory challenges in primary aldosteronism screening and diagnosis. Clin Biochem 2015; 48: 377-387.
- 20. Mulatero P, Rabbia F, Milan A, et al. Drug effects on aldosterone/plasma renin activity ratio in primary aldosteronism. Hypertension 2002; 40: 897-902.
- 21. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016; 101: 1889-1916.
- 22. O’Shea PM, Griffin TP, Browne GA, et al. Screening for primary aldosteronsim using the newly developed IDS-iSYS automated assay system. Pract Lab Med 2016; 7: 6-14.
- 23. Mulatero P, Stowasser M, Loh KC, et al. Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab 2004; 89: 1045-1050.
- 24. Teng J, Hutchinson ME, Doery JCG, et al. Role of adrenal vein sampling in primary aldosteronism: the Monash Health experience. Intern Med J 2015; 45: 1141-1146.
- 25. Mulatero P, Monticone S, Burrello J, et al. Guidelines for primary aldosteronism: uptake by primary care physicians in Europe. J Hypertens 2016; 34: 2253-2257.
- 26. Lubitz CC, Economopoulos KP, Sy S, et al. Cost-effectiveness of screening for primary aldosteronism and subtype diagnosis in the resistant hypertensive patients. Circ Cardiovasc Qual Outcomes 2015; 8: 621-630.
- 27. Sato M, Morimoto R, Seiji K, et al. Cost-effectiveness analysis of the diagnosis and treatment of primary aldosteronism in Japan. Horm Metab Res 2015; 47: 826-832.
- 28. Sywak M, Pasieka JL. Long-term follow-up and cost benefit of adrenalectomy in patients with primary hyperaldosteronism. Br J Surg 2002; 89: 1587-1593.
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The Hudson Institute of Medical Research is supported by the Victorian Government’s Operational Infrastructure Support Program. We acknowledge the assistance of Christopher Harrison, Research Fellow at the Menzies Centre for Health Policy, University of Sydney, for extracting data on the diagnoses of PA from the BEACH study. We also thank John Funder for his enthusiastic support and inspirational guidance in advocating for a greater appreciation of PA.
No relevant disclosures.